Final answer:
SOAP notes are medical documentation that includes Subjective and Objective information from the patient, an Assessment by the healthcare provider, and a Plan for the patient's management and treatment. These notes ensure effective communication among healthcare providers and accurate tracking of a patient's care. The correct option is 1) Subjective information and 2) Objective information
Step-by-step explanation:
Basic Information Included in SOAP Notes
The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, which are the core components included in medical SOAP notes. These notes are a fundamental part of medical documentation, used to record and communicate the details of a patient’s visit to healthcare providers.
- Subjective information comprises the patient’s perspective, symptoms, and feelings, as well as the history provided by the patient. It is essentially what the patient reports about their own health condition.
- Objective information includes measurable, observable, and reproducible data obtained through physical examination, laboratory results, and other diagnostic procedures. It is factual information about the patient's condition.
- Assessment is the healthcare provider’s professional interpretation of subjective and objective information, leading to a diagnosis or a list of possible diagnoses.
- The plan outlines the proposed management of the patient's condition, including treatments, medications, tests, or follow-ups required.
In practice, this process is demonstrated when a nurse reviews items aloud with the team, such as confirming that the procedure's name is recorded, that needle, sponge, and instrument counts are complete, that any specimens are correctly labeled, and that there are no issues with the equipment to be addressed. The correct option is 1) Subjective information and 2) Objective information